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Posts Tagged ‘evidence based cardiology’

The current  fad called EBM has lots of lacunae. Though evidence based approach is  considered  the ultimate  journey  towards  truth  ,lot of non academic factors contaminate it .In it’s  current form , it is difficult to comprehend it.

This is an attempt to decode the mystery of EBM  expressed in a simplified  lay person’s term .They are the ones  from whom we learn  medicine. They are our teachers in the true sense.

evidence based cardiology guidelines evidecne levelBy the way ,it  is also my approach  to   EBM .Sorry , if  this post  sounds  arrogant ! It is not the intention .Truths often times appear brutal .

And   . . . the  Genius  approach to EBM  for comparison

 

2011_AHA_Classification

 

 

 

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Off label prescription 

  1. Is a great scientific concept
  2. Is a deceit camouflaged  with a pseudo scientific fabric.
  3. Can be encouraged in very selective patient  population and diseases by experienced  cardiologists , as  it may be really useful when no other options are available.
  4. Is diagonally opposite  to evidence based medicine , should be banned in toto !

Answer:

4 is the correct answer .occasionally 3 can be true

Some of the examples of off label indication

  • Statins for Aortic stenosis
  • VSD device for RSOV closure
  • Ivabradine for cardiac failure

By the way how does an off label become on label?

It is not the ” God ” who  gives the label to them

There are few “Demi Gods” sitting aside  in the regulatory corridors of  New york and  Geneva who decide the fate of these drugs and devices . Ultimately the integrity of these organizations that will either protect or injure our patients !

Final message

Medical science grows my mistakes  . . . hence  we should be encouraged to do more of that  . . . so that we can grow !

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There are about 5000 medical journals ,  churning out tens of thousands of articles every month .Most of these  papers  come from developed world where publication is made mandatory to get a medical  degree . So it is not surprising  to find   proliferation of medical journals .

Publishing a paper is strictly monitored by a peer reviewing system in most journals . But , it is also a fact an article rejected  out right  by a journal , invariably appear in some other journal.

There is a joke going around among medical researchers,  if it is difficult to get your article published in a  journal , you start your own journal . . .It is much easier !

Where is the problem ?

Further  , bulk of current day research work is sponsored by drug and device companies .It is possible these papers may have 100% acceptance rate.

Brighter side

Even in this scenario , it is heartening to find  occasional  excellent  academic  treasures  and landmark research articles .

How common is irrelevant , pseudo , futile  , clinical research  articles  published  in medical journals  today ?

I agree , I  have prejudiced  view  on this issue . I  would like to know am I  really wrong ? What is your take on this issue ?

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Which you think is the most important journal in cardiology ?

  • JACC ?
  • Circulation ?
  • American journal of cardiology ?
  • American heart journal ?
  • Heart rhythm ?
  • European heart journal ?
  • The Heart  ?
  • Journal of invasive cardiology ?
  • NEJM ?
  • Lancet ?

None of the above  . . . is the right answer !

Probably,  the best journal  that is going to have the  greatest impact in cardiology practice in the future  could be  this  . . .

 Unfortunately  most  cardiologists are unaware of   this journal . The need for this journal , that  too from most respected Circulation family , will vouch for its importance in the current era  of  cardiology  that is driven more by the market forces than by the academics.

Click here  to reach  journal

Journal  Highlights

  • This  journal is 3 year old , and most of the medical colleges   do not subscribe to this.
  • None of the 100  cardiologists  who were questioned , were unaware of such a journal.
  • Even those who read this journal often term as boring  , academic and not practical !

 

The Circulation team which  started this journal  with  only one purpose  . . .that is ,  auditing the uncontrolled  proliferation of  pseudoscientific literature without proper quality assessment and dubious outcomes. Three cheers to the circualtion team for publishing this journal and let us propogate the importance of this publication.

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This is a real life experience of  a patient who underwent a electrophysiology study and   ablation   procedure for atrial fibrillation  .The blog describes  how the procedure became a nightmare .Written in a  most  readable fashion .  Interventional cardiologists need  not get hurt by this  narration  instead  they should  do a  reality check on the dangers  of  the some  of the  complex  procedures !

Adventures in Cardiology

Click over the  image to  read the real  time experience of   Pulmonary vein  ablation

Image courtesy Mayo clinic

The message from the above story  :

  • Atrial fibrillation is  one of the  relatively  benign  cardiac arrhythmia , that  can be treated  with   simple and effective  drugs . Now we have strong evidence to say rate control is equally , if not more effective than the rhythm control  modalities .
  • The RF  ablation  , which aims at rhythm control  is a too complex a procedure with  lots of expertise  technology  .
  • This should be  reserved  as a last resort  in an occasional patient who had exhausted all other  options .
  • Patients should  realise ,  the consent forms they sign  before any new and innovative  procedure is always  incomplete and  he may be the first person to experience  a new complication  hitherto unreported .
  • A cath lab is run by a team ,  you can’t  expect  the chief doctor to be on your  side always.   Many of the procedures  are  done by either experienced or inexperienced  fellows . That’s  only the  way medicine  can be practiced !
  • So beware all patients , many times, modern medicine is nothing but  experiments on live humans  !



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Modern era of cardiology aims to treat ACS  as and when it develops .That is , as soon as the vulnerable plaque ruptures or a thrombus  blocks the victim’s coronary artery.

But this can be achieved only if the patient reacts to this event.We know 20% of ACS can be totally silent. Some produce very vague symptoms especially in elderly and diabetics. ECG and enzyme changes may help us in patients who do not have clear symptoms.There are variety of markers available for STEMI & UNSTEMI.(CPK-MB, Troponin T , myoglobin etc) Now we are working at finding a marker for ischemia without necrosis. Ischemia modified albumin is one such molecule that is showing promise.

The ER department world over have vigorous screening protocols to diagnose ACS  for  the patients with chest pain. There are thousands of triaging protocol in the  emergency management of chest pain.In spite of  the highest awareness and availability of  scientific expertise , knowledge base the error rate of diagnosing  ACS  stands at an astonishing 58%.  This may seem odd , but this is what  this land mark article in NEJM tell us  (Data from Boston , Milwaukee etc).

Out of 10500 patients with suspected ACS. Only 17 % had real ACS.  55% were admitted initially as ACS  later turned out to be non cardiac .This may seem  acceptable for many  even if it is  an act of unnecessary admission and investigation. It gives us , a sense of satisfaction for not missing a diagnosis of ACS. But it has it’s own risk of complication arising out of unnecessary investigations.It is a chain reaction of  suspicion that  may end up in a coronary angiogram in many ! .It is also a well recognised fact these patients    spend  atleast an average of  2 days  to get rid of the ACS tag over their  necks .

Experience has taught us  simple presence of a human being as a patient within an  ICU ( however short the stay  may be ) can be a health hazard and risk .  This  55 % error ,  which does exactly  this to  our  patients with chest pain  who reach the ER  never bothers us  This is because  we feel credited both academically as well as financially .

In the same study 2.3 %  (About 25 patients) with true ACS  were sent home  after a missed  diagnosis . Paradoxically  this 2.3%  has worried the medical professionals too much . . . This happens  ,  even as we  do not have proper data on  how many of them had a real adverse event after a missed  ACS.

So the message here is even in best centres both missed and wrong diagnosis are  rampant. while wrong diagnosis (25 fold more here  )  is easily accepted by the medical community .We can justify  this as a screening camp for ACS  ,  akin to arresting  a group of suspected  criminals in a  preventive raid ,  later releasing for want of evidence.

In the morals of  criminal judiciary  , it is often said one can afford to  lose  a real offender from the clutches of law  , but a  innocent should  never be punished in any circumstance .

In medical parlance this  goes something like this  . . . Thousand patients shall die because of his or her illness but not even a single healthy person should die due to unnecessary treatment.

The above thoughts  were in response to  the excellent original article on missed diagnosis  of ACS from NEJM.  http://content.nejm.org/cgi/content/full/342/16/1163?ijkey=652d8337709a8bf84c813f4c9d685863ee053162

Final message : (Sorry for the  lengthy message !)

Can we afford to miss an  ACS in emergency room ?

“Definitely not” . . .but do we succeed in that ?  The answer is same “definitely not “

When we are able to accept with pride every time  we make  a  wrong diagnosis of  ACS  in perfectly normal people , It may to provocative to say  we can  also  afford  to do  the same  when we occasionally   miss a  diagnosis of ACS  as well .  Law of statistics dictates for every correct diagnosis made there is many fold number of wrong or missed diagnosis takes place. May be , reducing that is the only aim of medicine.

We need to realise  with even with a 55% of false positive initial  diagnosis  2%  real ACS  escape net !The only  fool proof method  for  not missing  ,  even a single case of ACS   is to label every patient with chest pain as ACS .

In this vexing  issue , we should realise  , in field of  medical decision  making ,  errors  due to acts of commission  ( Making an  inappropriate drug/procedure /surgery  is easily accepted by medical professionals as well as   the court of law !) . But acts of omission ,   like missing a diagnosis or failure to prescribe  a  drug or perform a procedure  is rarely accepted   and  is  considered   a great negligence and  bring intense guilty feeling among the physicians .

This  perception is definitely  not warranted in this  greatest profession  of glorious uncertainties ! Both acts of commission and omission  cause significant damage to  patients . In this modern era  ,  we have clear  statistics  that   reveal ,  acts of commission  leads far ahead over it’ s counterpart in injuring our people .

Hippocrates got it right over 2000 years  ago .  First let us do no harm  . . .

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cardiologist Is he a person who puts  a   metal coil  coated with a synthetic fungus   in  a   incidentally  detected  block  inside a  small coronary artery and sends the bill to the Insurance company ?

Is he a person in a  cosmopolitan  hospital  who opens up a    chronically   closed  coronary artery , in an asymptomatic patient  and  live telecasts  his achievement trans continentally ?

Is he a person who   checks in by  the early morning flight and  puts multiple wires in  an  aged   patient   with  class 3 heart failure and  make  him walk  20 meters extra at a cost of  1000$ / Meter ?

Is he a person living in   Wall   street  ,   who   looks  for variety of holes In  the heart and trying to occlude  it  with   exotic   devicespci ptca stent

Is he the unknown   physician   who Intervenes in the natural history of Rheumatic heart disease   and arrests   immune mediated   valve damage by giving the  monthly injections  penicillin in remote parts of our country ?

Is he the person   who   Intervenes to prevent young   persons   from  smoking and help maintain  their  coronary endothelium  enriched with nitric oxide  & arrest  the coronary epidemic ?

cardiologist 2

Is he the small town doctor  who  Intervenes  to treat a breathless cardiac failure patient  with  digoxin and frusemide  and  dramatically alleviate the  symptoms and  prolong the  life of our poor country men?

Is she the village health nurse from an inaccessible health  centre  located in a  hilly terrain ,  Intervening  successfully, by   pulling out  live babies  from  severely anemic pregnant  mothers with failing hearts ?

pci ptca cardiologist coronary angiograms

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